Knowledge and perceptions of quality of obstetric and newborn care of local health providers: A cross-sectional study in three districts in Malawi

AimQuality of service delivery for maternal and newborn health in Malawi isinfluenced by human resource shortages and knowledge and care practicesof the existing service providers. We assessed Malawian healthcareproviders’ knowledge of management of routine labour, emergencyobstetric care and emergency newborn care; correlated knowledgewith reported confidence and previous study or training; and measuredperception of the care they provided.MethodsThis study formed part of a large-scale quality of care assessment inthree districts (Kasungu, Lilongwe and Salima) of Malawi. Subjects wereselected purposively by their role as providers of obstetric and newborncare during routine visits to health facilities by a research assistant. Researchassistants introduced and supervised the self-completed questionnaire bythe service providers. Respondents included 42 nurse midwives, 1 clinicalofficer, 4 medical assistants and 5 other staff. Of these, 37 were staffworking in facilities providing Basic Emergency Obstetric Care (BEMoC)and 15 were from staff working in facilities providing ComprehensiveEmergency Obstetric Care (CEMoC).ResultsKnowledge regarding management of routine labour was good (80%correct responses), but knowledge of correct monitoring during routinelabour (35% correct) was not in keeping with internationally recognizedgood practice. Questions regarding emergency obstetric care were  answered correctly by 70% of respondents with significant variation depending on clinicians’ place of work. Knowledge of emergency newborn care was poor across all groups surveyed with 58% correct responses and high rates of potentially life-threatening responses from BEmOC facilities. Reported confidence and training had little impact on levels of knowledge. Staff in general reported perception of poor quality of care.ConclusionSerious deficiencies in providers’ knowledge regarding monitoring duringroutine labour and management of emergency newborn care weredocumented. These may contribute to maternal and neonatal deaths inMalawi. The knowledge gap cannot be overcome by simply providingmore training

Improving the standards-based management: recognition initiative to provide high-quality, equitable maternal health services in Malawi. An implementation research protocol: Table 1

Background: The Government of Malawi is seeking evidence to improve implementation of its flagship quality of care improvement initiative — the Standards Based Management-Recognition for Reproductive Health (SBM-R(RH)). Objective: This implementation study will assess the quality of maternal healthcare in facilities where the SBM-R(RH) initiative has been employed, identify factors that support or undermine effectiveness of the initiative and develop strategies to further enhance its operation. Methods: Data will be collected in 4 interlinked modules using quantitative and qualitative research methods. Module 1 will develop the programme theory underlying the SBM-R(RH) initiative, using document review and in-depth interviews with policymakers and programme managers. Module 2 will quantitatively assess the quality and equity of maternal healthcare provided in facilities where the SBM-R(RH) initiative has been implemented, using the Malawi Integrated Performance Standards for Reproductive Health. Module 3 will conduct an organisational ethnography to explore the structures and processes through which SBM-R(RH) is currently operationalised. Barriers and facilitators will be identified. Module 4 will involve coordinated co-production of knowledge by researchers, policymakers and the public, to identify and test strategies to improve implementation of the initiative. Potential impact: The research outcomes will provide empirical evidence of strategies that will enhance the facilitators and address the barriers to effective implementation of the initiative. It will also contribute to the theoretical advances in the emerging science of implementation research

Socio-demographic factors associated with early antenatal care visits among pregnant women in Malawi: 2004-2016

INTRODUCTION: In 2016, the WHO published recommendations increasing the number of recommended antenatal care (ANC) visits per pregnancy from four to eight. Prior to the implementation of this policy, coverage of four ANC visits has been suboptimal in many low-income settings. In this study we explore socio-demographic factors associated with early initiation of first ANC contact and attending at least four ANC visits ("ANC4+") in Malawi using the Malawi Demographic and Health Survey (MDHS) data collected between 2004 and 2016, prior to the implementation of new recommendations. METHODS: We combined data from the 2004-5, 2010 and 2015-16 MDHS using Stata version 16. Participants included all women surveyed between the ages of 15-49 who had given birth in the five years preceding the survey. We conducted weighted univariate, bivariate and multivariable logistic regression analysis of the effects of each of the predictor variables on the binary endpoint of the woman attending at least four ANC visits and having the first ANC attendance within or before the four months of pregnancy (ANC4+). To determine whether a factor was included in the model, the likelihood ratio test was used with a statistical significance of P< 0.05 as the threshold. RESULTS: We evaluated data collected in surveys in 2004/5, 2010 and 2015/6 from 26386 women who had given birth in the five years before being surveyed. The median gestational age, in months, at the time of presenting for the first ANC visit was 5 (inter quartile range: 4-6). The proportion of women initiating ANC4+ increased from 21.3% in 2004-5 to 38.8% in 2015-16. From multivariate analysis, there was increasing trend in ANC4+ from women aged 20-24 years (adjusted odds ratio (aOR) = 1.27, 95%CI:1.05-1.53, P = 0.01) to women aged 45-49 years (aOR = 1.91, 95%CI:1.18-3.09, P = 0.008) compared to those aged 15-19 years. Women from richest socio-economic position ((aOR = 1.32, 95%CI:1.12-1.58, P<0.001) were more likely to demonstrate ANC4+ than those from low socio-economic position. Additionally, women who had completed secondary (aOR = 1.24, 95%CI:1.02-1.51, P = 0.03) and tertiary (aOR = 2.64, 95%CI:1.65-4.22, P<0.001) education were more likely to report having ANC4+ than those with no formal education. Conversely increasing parity was associated with a reduction in likelihood of ANC4+ with women who had previously delivered 2-3 (aOR = 0.74, 95%CI:0.63-0.86, P<0.001), 4-5 (aOR = 0.65, 95%CI:0.53-0.80, P<0.001) or greater than 6 (aOR = 0.61, 95%CI: 0.47-0.79, <0.001) children being less likely to demonstrate ANC4+. CONCLUSION: The proportion of women reporting ANC4+ and of key ANC interventions in Malawi have increased significantly since 2004. However, we found that most women did not access the recommended number of ANC visits in Malawi, prior to the 2016 WHO policy change which may mean that women are less likely to undertake the 2016 WHO recommendation of 8 contacts per pregnancy. Additionally, our results highlighted significant variation in coverage according to key socio-demographic variables which should be considered when devising national strategies to ensure that all women access the appropriate frequency of ANC visits during their pregnancy

Effects of quality improvement in health facilities and community mobilization through women's groups on maternal, neonatal and perinatal mortality in three districts of Malawi: MaiKhanda, a cluster randomized controlled effectiveness trial

BACKGROUND: Maternal, perinatal and neonatal mortality remains high in low-income countries. We evaluated community and facility-based interventions to reduce deaths in three districts of Malawi. METHODS: We evaluated a rural participatory women's group community intervention (CI) and a quality improvement intervention at health centres (FI) via a two-by-two factorial cluster randomized controlled trial. Consenting pregnant women were followed-up to 2 months after birth using key informants. Primary outcomes were maternal, perinatal and neonatal mortality. Clusters were health centre catchment areas assigned using stratified computer-generated randomization. Following exclusions, including non-birthing facilities, 61 clusters were analysed: control (17 clusters, 4912 births), FI (15, 5335), CI (15, 5080) and FI + CI (14, 5249). This trial was registered as International Standard Randomised Controlled Trial [ISRCTN18073903]. Outcomes for 14 576 and 20 576 births were recorded during baseline (June 2007–September 2008) and intervention (October 2008–December 2010) periods. RESULTS: For control, FI, CI and FI + CI clusters neonatal mortality rates were 34.0, 28.3, 29.9 and 27.0 neonatal deaths per 1000 live births and perinatal mortality rates were 56.2, 55.1, 48.0 and 48.4 per 1000 births, during the intervention period. Adjusting for clustering and stratification, the neonatal mortality rate was 22% lower in FI + CI than control clusters (OR = 0.78, 95% CI 0.60–1.01), and the perinatal mortality rate was 16% lower in CI clusters (OR = 0.84, 95% CI 0.72–0.97). We did not observe any intervention effects on maternal mortality. CONCLUSIONS: Despite implementation problems, a combined community and facility approach using participatory women's groups and quality improvement at health centres reduced newborn mortality in rural Malawi

Publisher Correction: Genetic tool development in marine protists: emerging model organisms for experimental cell biology.

An amendment to this paper has been published and can be accessed via a link at the top of the paper

Genetic tool development in marine protists: emerging model organisms for experimental cell biology

Abstract: Diverse microbial ecosystems underpin life in the sea. Among these microbes are many unicellular eukaryotes that span the diversity of the eukaryotic tree of life. However, genetic tractability has been limited to a few species, which do not represent eukaryotic diversity or environmentally relevant taxa. Here, we report on the development of genetic tools in a range of protists primarily from marine environments. We present evidence for foreign DNA delivery and expression in 13 species never before transformed and for advancement of tools for eight other species, as well as potential reasons for why transformation of yet another 17 species tested was not achieved. Our resource in genetic manipulation will provide insights into the ancestral eukaryotic lifeforms, general eukaryote cell biology, protein diversification and the evolution of cellular pathways

Genetic tool development in marine protists: emerging model organisms for experimental cell biology

Abstract: Diverse microbial ecosystems underpin life in the sea. Among these microbes are many unicellular eukaryotes that span the diversity of the eukaryotic tree of life. However, genetic tractability has been limited to a few species, which do not represent eukaryotic diversity or environmentally relevant taxa. Here, we report on the development of genetic tools in a range of protists primarily from marine environments. We present evidence for foreign DNA delivery and expression in 13 species never before transformed and for advancement of tools for eight other species, as well as potential reasons for why transformation of yet another 17 species tested was not achieved. Our resource in genetic manipulation will provide insights into the ancestral eukaryotic lifeforms, general eukaryote cell biology, protein diversification and the evolution of cellular pathways

Can training in advanced clinical skills in obstetrics, neonatal care and leadership, of non-physician clinicians in Malawi impact on clinical services improvements (the ETATMBA project) : a process evaluation

Objectives The ‘enhancing human resources and the use of appropriate technologies for maternal and perinatal survival in sub-Saharan Africa’ (ETATMBA) project is training emergency obstetric and new-born care (EmONC) non-physician clinicians (NPCs) as advanced clinical leaders. Our objectives were to evaluate the implementation and changes to practice. Design A mixed methods process evaluation with the predominate methodology being qualitative. Setting Rural and urban hospitals in 8 of the 14 districts of northern and central Malawi. Participants 54 EmONC NPCs with 3 years’ plus experience. Intervention Training designed and delivered by clinicians from the UK and Malawi; it is a 2-year plus package of training (classroom, mentorship and assignments). Results We conducted 79 trainee interviews over three time points during the training, as well as a convenience sample of 10 colleagues, 7 district officers and 2 UK obstetricians. Trainees worked in a context of substantial variation in the rates of maternal and neonatal deaths between districts. Training reached trainees working across the target regions. For 46 trainees (8 dropped out of the course), dose delivered in terms of attendance was high and all 46 spent time working alongside an obstetrician. In early interviews trainees recalled course content unprompted indicating training had been received. Colleagues and district officers reported cascading of knowledge and initial changes in practice indicating early implementation. By asking trainees to describe actual cases we found they had implemented new knowledge and skills. These included life-saving interventions for postpartum haemorrhage and eclampsia. Trainees identified the leadership training as enabling them to confidently change their own practice and initiate change in their health facility. Conclusions This process evaluation suggests that trainees have made positive changes in their practice. Clear impacts on maternal and perinatal mortality are yet to be elucidated

Use of mHealth tools to register birth outcomes in low-income and middle-income countries: a scoping review

Objective Accurate reporting of birth outcomes in low-income and middle-income countries (LMICs) is essential. Mobile health (mHealth) tools have been proposed as a replacement for conventional paper-based registers. mHealth could provide timely data for individual facilities and health departments, as well as capture deliveries outside facilities. This scoping review evaluates which mHealth tools have been reported to birth outcomes in the delivering room in LMICs and documents their reported advantages and drawbacks. Design A scoping review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Joanna Briggs Institute guidelines for scoping reviews and the mHealth evidence reporting and assessment checklist for evaluating mHealth interventions. Data sources PubMed, CINAHL and Global Health were searched for records until 3 February 2022 with no earliest date limit. Eligibility criteria Studies were included where healthcare workers used mHealth tools in LMICs to record birth outcomes. Exclusion criteria included mHealth not being used at the point of delivery, non-peer reviewed literature and studies not written in English. Data extraction and synthesis Two independent reviewers screened studies and extracted data. Common themes among studies were identified. Results 640 records were screened, 21 of which met the inclusion criteria, describing 15 different mHealth tools. We identified six themes: (1) digital tools for labour monitoring (8 studies); (2) digital data collection of specific birth outcomes (3 studies); (3) digital technologies used in community settings (6 studies); (4) attitudes of healthcare workers (10 studies); (5) paper versus electronic data collection (3 studies) and (6) infrastructure, interoperability and sustainability (8 studies). Conclusion Several mHealth technologies are reported to have the capability to record birth outcomes at delivery, but none were identified that were designed solely for that purpose. Use of digital delivery registers appears feasible and acceptable to healthcare workers, but definitive evaluations are lacking. Further assessment of the sustainability of technologies and their ability to integrate with existing health information systems is needed.</p